Technika Transuretral Prepact resection. Application of Laparoscopy in Upper Urinary Tract Surgery - PDF Ingyenes letöltés


Gabor Jancso Thesis Supervisor: Prof. Laszlo Farkas Honorary Advisor: Prof.

Acute kidney injury Adenosine Monophosphate. Analysis of Variance. Acute Tubular Necrosis. Adenosine Triphosphate. Glomerular Filtration Rate. Renal Cell Carcinoma Renal Function Radical Nephrectomy Region Of Interest Serum Creatinine. Total Differential Renal Function Ultrasound Warm Ischemia. Warm Ischemia Time The objective of surgical therapy is to excise the entire tumour with an adequate surgical margin.

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InRobson and colleagues established radical nephrectomy RN as the gold standard curative operation for localized RCC. In the past three decades, the increased use of imaging modalities such as ultrasound US and computerized tomography CT has led to increase the number of incidentally detected renal masses. Tumours detected by imaging techniques tend to be smaller, lower stage lesions that are typically amenable to partial nephrectomy PN. The main aim of this surgical procedure is maximal preservation of unaffected renal parenchyma without sacrificing cancer control.

During the last several years, refinements in the surgical technique of PN have made this procedure technically safe with acceptable complication rates. Long-term outcome data indicate that open partial nephrectomy OPN has cancer-free survival rates comparable to those of radical surgery with better preservation of renal function RFreduced frequency of cardiovascular events, and decreased overall mortality rate.

RN is no longer the gold standard treatment in these cases. It has been proved that, in these cases, NSS for tumours limited in diameter to 4 cm pt1a provides recurrence-free and long-term survival rates similar Technika Transuretral Prepact resection those observed after radical surgery. For larger tumours pt1bPN has demonstrated feasibility and oncological safety in carefully selected patients.

The impact of laparoscopy has increased rapidly within the last two decades, and as Peponen a prosztatitisből result, laparoscopic radical nephrectomy has become a recognized standard surgical approach by the EAU guidelines. Many laparoscopic surgeons were confronted with the situation that they could offer radical nephrectomy by means of laparoscopy but they had difficulties to perform laparoscopic NSS for the small tumors.

Thus, in the past Technika Transuretral Prepact resection years, great efforts have been directed towards the 3 4 development of reliable and reproducible techniques for laparoscopic partial nephrectomy LPN AIM OF THE STUDY To learn the upper urinary tract laparoscopy from international leading urologists in the field, to overcome the learning phase and develop modifications of standard laparoscopic techniques. To design a study to answer some challenging questions in relation to the impairment of renal function after partial nephrectomy: a.

What is the minimal renal ischemia time which can lead to kidney damage? What recept a prosztatitis mézzel the maximum ischemia time which can be tolerated by the majority of kidneys? Are there other factors which may worsen the damage?

Are there Technika Transuretral Prepact resection substances which can prolong ischemia time? What is the impact of volume reduction on renal function outcome after partial nephrectomy? Ischemia time can be increased substantially by cooling of the renal parenchyma, which is easily induced during open surgery.

When comparing laparoscopy with open surgery, ischemia time is longer even in the most experienced hands and hypothermia for protection of the renal function is difficult to achieve. Several attempts have been made to overcome the aforementioned problems in laparoscopic approaches. Cold ischemia is applied in cases where longer ischemic time is expected. The time available to complete the resection and repair of collecting system and parenchyma during warm ischemia is limited Technika Transuretral Prepact resection the surgeon has to race against the clock.

Renal cooling during ischemia protects the kidney and offers the surgeon extra time.

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The problem of renal cooling during ischemia when performing laparoscopic PN has not been solved yet. Inwe presented our first experience with renal cooling during laparoscopic surgery for small RCC by means of cold arterial perfusion. Patients and methods Between November and Marchwe performed laparoscopic PN in cold ischemia in 17 patients.

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The indication was suspected RCC in 15 patients with a mean tumor size of 2. In all patients, preoperative angio-mri was performed to visualize the renal artery s. Preoperative renal scintigraphy DMSA was done to have a baseline data about the renal function for follow-up.

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Placement of an open tip ureteric catheter was done under fluoroscopy to be used later to check the integrity of the collecting system. Next, an angiocatheter was passed into the main renal artery through a femoral puncture on the ipsilateral side. This procedure was carried out by one of our interventional radiologists. Then the patient was brought to degree lateral decubitus position. In this final position for laparoscopic surgery, the angiocatheter was checked again and advanced in the renal artery close to the origin of the segmental arteries if needed.

Port placement varied 5 6 according to the tumor location. The renal artery was secured and later on occluded using a tourniquet. Results and Technika Transuretral Prepact resection Laparoscopic PN with our technique could be performed successfully in all patients with no conversion. The mean intraoperative blood loss was ml 30 Only one patient required intraoperative blood transfusion.

Mean total ischemia time was 41 minutes min. Entry to the Technika Transuretral Prepact resection system happened in 7 patients and was repaired intraoperatively. Mean amount of perfusate was 1, ml 1, Mean decrease of body temperature during cold perfusion was 0. Mean operative time was minutes.

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Urethral and ureteric catheters were removed on the second postoperative day. Mean hospital stay was 9. Bleeding occurred in Technika Transuretral Prepact resection case in the first postoperative day due to parenchymal tear from the sutures. This was managed laparoscopically by bipolar coagulation and application of a strip of Tachocomb.

No urinary fistula or urinoma were encountered. The histopathological examination revealed RCC in 13 patients, angiomyolipoma in 2, and pyelonephretic renal tissue in another 2. The resection margins were negative in 14 patients. In one patient, negative margin was not described where the tumor was in direct contact with the renal vein. During resection the vein was entered and repaired.

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Postoperative renal function was evaluated in 8 patients. In the other 3 patients, CT scan showed undisturbed perfusion of the renal parenchyma. We concluded that the reduction in renal function was most probably attributed to reduction in the total renal volume after wedge resection.

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In our series, we didn t encounter any problem regarding the renal function or the amount of perfusate used. This is probably because all the patients were with a normal contralateral kidney and diuresis was induced prior, during and after ischemia. However in a solitary kidney, one should be aware of the risk of volume overload resulting from the non-excretion of the perfusate during temporary renal ischemia. In this case excretion of the perfusate will depend on the fast recovery of the kidney after ischemia.

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Hilar occlusion is commonly performed for a precise tumour resection and renal reconstruction. The above surgical manoeuvre results in warm ischemia WI of the remaining renal tissue and has been associated with ischemicreperfusion injury RI to the organ. Current evidence showed that the length of the warm ischemia time WIT and the subsequent reperfusion injury may result in permanent renal damage Becker et al ; Simmons et al Moreover, the resection of the renal tumour and the suturing of the parenchyma resulted in additional reduction of the functional renal tissue Simmons et al ; Song et al Thus, two mechanisms of renal function damage during PN could be proposed.

Application of Laparoscopy in Upper Urinary Tract Surgery - PDF Ingyenes letöltés

Nevertheless, the importance of the mechanisms for the decline of the postoperative renal function has not been investigated.

The current prospective study evaluated the split renal function and elucidated the role of renal parenchymal loss in patients with small renal mass who were treated by LPN with WI. Patients and methods Thirty five patients were enrolled in a prospective study.

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The procedures were performed by two experienced laparoscopists. The exact location and dimensions of the tumour was identified by three-dimensional CT scan prior to the operation. Only patients with a single exophytic mass of 4 cm in diameter located in either lower or upper pole of the kidney with normal contralateral Technika Transuretral Prepact resection were enrolled.

Application of Laparoscopy in Upper Urinary Tract Surgery

The recorded parameters included the time for tumour resection, calyceal closure, haemostatic sutures and the total WIT. Serum creatinine scr was recorded and estimated glomerular filtration rate egfr was calculated. The above measurements were performed preoperatively baselinehours after the surgery, on the 1 st, 3 rd and 7 th postoperative days and at the end of 1 st, 3 rd, 6 th, and 12 th postoperative months.

In order to distinguish the impact of parenchymal loss from WI effect on the operated kidney, we planned a novel method of investigation with renal scan as follow. Technika Transuretral Prepact resection patients in LPN group underwent 99m Technetium-Dimercaptosuccinic 7 8 Acid 99mTc-DMSA renal scintigraphy for the determination of split renal function preoperatively and at the end of 1 st, 3 rd, 6 th, and 12 th postoperative months.

Since 99mTc-DMSA scan provides relative functional percentage of the two kidneys and the contralateral kidney served as a control for comparison after LPN, we selected patients with solitary small polar mass T1aotherwise normal ipsilateral kidney, and normal contralateral kidney. Technika Transuretral Prepact resection the operation, all patients underwent radionuclide isotope examination performed by 99mTc-DMSA.

Renal scans were performed in supine position. Individual kidney uptake and differential renal function DRF percentage of left-toright kidneys were determined by the Patlak-Rutland method.

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The region of interest ROI of each kidney was determined with the use of an automated computer program drawing the ROI around the whole kidney. By this means, in the tumorous kidney, the postoperative decline in percentage ratio, reflecting decrease in renal function, was considered as a consequence of both factors: 1. IR injury caused by length of WIT. The kidney parenchymal volume reduction caused by removal of the tumour, and excision and suturing of the surrounding healthy tissues. For this reason, in the preoperative renal scans, the exact location of the tumour was determined and only small polar masses either upper or lower pole mass were selected for the study.

In the tumorous Technika Transuretral Prepact resection, a region in the tumour-free pole was selected and manually a ROI was drawn in that pole. The same ROI drawing was used in all follow-up studies of a given patient. Accordingly, P-DRF which reflects DRF of the intact pole of the operated kidney, which is affected only by the IR injury, was compared with the same pole Technika Transuretral Prepact resection the contralateral kidney.

The same processing was applied for all patients in all isotope scan examinations.

As a result, in the postoperative isotope scans, with the P-DRF, we could compare an intact part of the operated kidney which was impacted by WI but not affected by parenchymal volume reduction with an identical segment of the normal contralateral kidney.